Staff engagement Six building blocks for harnessing the creativity and enthusiasm of NHS staff
Leadershipin action
What is staff engagement and why is it important?
Health care is a people business. The quality of care that
patients receive depends first and foremost on the skill
and dedication of NHS staff. Highly engaged staff – and
by this we mean individuals who are committed to their
organisations and involved in their roles – are more likely
to bring their heart and soul to work, to take the initiative,
to ‘go the extra mile’ and to collaborate effectively
with others.
There is now an overwhelming body of evidence to show
that engaged staff really do deliver better health care.
The NHS providers with high levels of staff engagement
(as measured in the annual NHS Staff Survey) tend to
have lower levels of patient mortality, make better use of
resources and deliver stronger financial performance (West
and Dawson 2012). Engaged staff are more likely to have
the emotional resources to show empathy and compassion,
despite the pressures they work under. So it is no surprise
that trusts with more engaged staff tend to have higher
patient satisfaction, with more patients reporting that they
were treated with dignity and respect (Review of Staff
Engagement and Empowerment in the NHS 2014).
Yet despite the evidence, the question of how to create
an engaged workforce still struggles to make its way
on to the board agenda. It may seem like a vague concept,
and there are always other, seemingly more immediate
challenges. Mid Staffordshire NHS Foundation Trust had
What is staff engagement and why is it important?
among the lowest levels of staff engagement in the NHS
throughout the mid-2000s, but the alarm bells were not
heard. While levels of staff engagement have risen across
the NHS over the past few years, the disparities between
organisations are wider than ever. Those trusts with the
lowest levels of staff engagement are falling further behind
the leaders (Review of Staff Engagement and Empowerment
in the NHS 2014).
The good news is that we now know a huge amount, from
the NHS and other sectors, about the conditions that create
an engaged workforce. Developing engaged staff is a long-
term endeavour and requires sustained effort throughout an
organisation. But board members and other leaders can start
making a tangible difference immediately, simply by focusing
on the following six building blocks for success.
Six building blocks for a highly engaged workforce
1. Develop a compelling, shared strategic direction
4. Give staff the toolsto lead servicetransformation
2. Build collective and distributed leadership
5. Establish a culture based on integrity
and trust
3. Adopt supportive and inclusive
leadership styles
6. Place staff engagement firmly
on the board agenda
authenticity
VALUES
integrityHONESTY
compassion
fairness
TRUST
AGENDA
1. Staff
engagement
1Research from health care and other sectors shows that
leaders who help their organisations to develop a clear vision
and a compelling narrative about mission and priorities achieve
higher levels of staff engagement. Staff are more enthusiastic
about their work and collaborate more effectively, and this is
reflected in better performance (MacLeod and Clarke 2009).
In health care, there is evidence that developing a clear mission
focused on high quality, compassionate care helps to bridge
the fault lines between managers, clinicians and other groups
(Bezrukova et al 2012).
Achieving this is no easy feat and requires more than a well-
crafted mission statement. In health care, leaders face a
bewildering range of external expectations, which can lead
to overlapping or disjointed goals (Dixon-Woods et al 2014).
Successful providers have articulated simple but persuasive
visions for higher-quality, safer and more compassionate care
and have maintained them consistently over time. Salford Royal
NHS Foundation Trust announced its ambition to become the
safest NHS hospital in 2008 and it has retained that vision,
with minor changes, for the past seven years.
Just as importantly, the vision needs to be seen as authentic
and meaningful. Leaders need to demonstrate their commitment
to the vision through the way they spend their time, how
they allocate resources, what they measure and what they
reward, as well as by ensuring that the vision is reflected in
Develop a compelling, shared strategic direction
staff objectives across the organisation. The most successful
organisations set explicit and challenging goals for achieving
the vision and they measure progress in meeting them. Salford
Royal set an initial target of saving 1,000 lives in three years
and reported on progress in meeting it. Northumbria Healthcare
NHS Foundation Trust has published targets for quality
improvement, such as a new zero-tolerance strategy towards
hospital- and community-acquired pressure ulcers and falls in
hospital. It has set the target of a 20 per cent reduction in harm
from pressure ulcers and falls in 2014/15 and is publishing levels
of performance in its annual report.
The ultimate test of a vision has to be whether it transcends the
mission statement and enters the organisation’s bloodstream –
the rites, rituals, cultural norms and stories about ‘how we do
things around here’. In November 2014, staff at Wrightington,
Wigan and Leigh NHS Foundation Trust wheeled a 77-year-old
cancer patient into the hospital car park to say goodbye to the
horse she had cared for for more than 25 years. For staff, the
message from the story is clear: this is an organisation that really
is trying, as it claims in its mission statement, to put patients
‘at the heart of everything we do’, and is giving staff the freedom
and support to translate the vision into practice.
Board members should ask the following questions• Do senior leaders and staff agree that they are all working
towards a clearly defined common direction?
• Do staff across the organisation understand the vision
and how their roles contribute to it?
• Has the organisation set demanding goals for achieving
the vision and is it monitoring progress in meeting them?
The most successful health care providers – like high performers
in other sectors – are reducing reliance on top-down leadership
in favour of collective and distributed leadership, where all staff
are supported to play leadership roles. Rather than concentrating
power at the top, these providers are devolving decision-
making in their organisations, alongside major programmes of
cultural change, so that staff at all levels have the authority,
responsibility and resources to improve care.
We know that distributing power and authority in this way
helps to create a more engaged workforce. Research from
multiple sectors shows that staff are more engaged if they
have responsibility for their work and influence over their
working environment (Towers Perrin HR Services 2003).
Conversely, we know that staff are more likely to disengage
when operating in overly bureaucratic environments with
layers of hierarchy and control. According to Paul Plsek, Chair
of Innovation at the Virginia Mason Center in the United States,
‘a learning organisation seeks to develop skills in the process
of leadership at all levels of the organisation, and seeks to
flatten hierarchy and eliminate rigid policies’ (Plsek 2013).
However, we cannot underestimate the challenges of developing
a collective leadership culture within many NHS organisations,
given the legacy of rigid hierarchies and ‘command-and-control’.
For many top-performing providers, it requires huge commitment
2 Build collective and distributed leadership
to develop a new leadership philosophy. It takes time and
effort to redesign decision-making structures and equip staff
at different levels to play different roles, alongside concerted
programmes to deliver the necessary cultural change. In the early
2000s, University College London Hospitals NHS Foundation
Trust stripped out layers of management and gave clinicians
joint managerial and clinical responsibility for the performance of
their divisions, with the role of ensuring both quality of care and
financial sustainability.
Alongside these types of changes, staff at every level must
be given explicit authority to identify opportunities for
improvement or to raise concerns, and – just as importantly –
opportunities for these contributions to be considered fairly
and acted on. In manufacturing, Toyota and Alcoa famously
introduced the right for staff to stop the production line if they
identified a defect or a safety concern. In health care, forward-
thinking providers are developing similar approaches – not just
to improve safety, such as finding a lost swab in an operating
theatre, but also to tackle unacceptable behaviours in a caring
profession, such as discourtesy, bullying or harassment.
For a further discussion of these issues, see our other
recent publications: Exploring the CQC’s well-led domain:
how can boards ensure a positive organisational culture?
(Steward 2014) and Developing collective leadership for
health care (West et al 2014).
Board members should ask the following questions• Do we have a leadership strategy and a leadership
development plan?
• Do we have a clear understanding of our current leadership
culture and the leadership culture we are trying to create?
• What approaches have we developed to empower staff
throughout the organisation to play leadership roles?
• Are we absolutely sure that staff can speak up when they
have concerns and that their concerns are considered fairly?
Research shows that leaders and managers who adopt
supportive and inclusive leadership styles have more engaged
staff. The most successful leaders deploy a range of leadership
styles depending on the circumstances, but with greatest
reliance on inclusive styles, such promoting collaboration,
involving staff in decisions, encouraging and coaching staff,
and supporting staff in overcoming organisational challenges.
Yet despite this evidence, studies suggest that NHS leaders
and managers continue to rely first and foremost on directive
leadership styles such as leading from the front, setting the
pace or laying down demanding targets – precisely those styles
that run the greatest risk of disempowering and alienating staff.
According to the Commission on Dignity in Care for Older People:
‘if senior managers impose a command and control culture
that demoralizes staff and robs them of the authority to make
decisions, poor care will follow’ (NHS Confederation et al 2012).
A small number of high-performing NHS organisations have
made concerted efforts to develop more inclusive and supportive
leadership styles. For example, Oxleas NHS Foundation Trust
made substantial investment to convince sceptical leaders and
managers of the need to change, before helping them to ‘unlearn’
ingrained behaviours and develop a broader set of leadership
skills. In 2013, Oxleas was the mental health trust with the
highest levels of staff satisfaction in the quality of their work
and in the patient care being delivered (NHS Staff Survey 2013).
3 Adopt supportive and inclusive leadership styles
For more information on the impact of leadership and
management see: Staff care: how to engage NHS staff
and why it matters (The Point of Care Foundation 2014)
Board members should ask the following questions• What do we think are the most prevalent leadership styles
throughout our organisations?
• What do our staff think are the most prevalent leadership
styles? Do they think leaders and managers are inclusive
and supportive?
• What investment have we made to develop the leadership
styles that support high levels of staff engagement?
We know that staff are most engaged in their roles when they
have a degree of authority and control over their work and
environment, as well as the opportunity to stretch themselves
and to develop. Conversely, the least engaged staff are often
hourly workers with little authority or influence over their work.
The most successful health care providers – just like cutting-edge
organisations in manufacturing, transport and other sectors – are
giving their staff the tools and resources to lead transformation
from the front line. Rather than calling in external experts
to redesign services, they are using these resources to help
frontline staff master modern methods of quality improvement.
By investing in and empowering their staff, these organisations
are unleashing their employees’ enthusiasm and creativity to
improve how they do their work, creating a constituency of
leaders of change, rather than stubborn opponents to change.
In doing so, they are creating ‘learning organisations’ where
staff at all levels participate in continuous, daily improvements
in care – rather than one-off flurries of activity when an
organisation or service hits the buffers.
There are many ways of going about this. Like Virginia Mason,
the Mayo Clinic and other international leaders, Salford
Royal NHS Foundation Trust has established a Performance
Improvement Directorate to support staff in developing and
testing service improvements. Others, such as University
4 Give staff the tools to lead service transformation
Hospitals of Leicester NHS Trust, are using Listening into
Action or similar methodologies to deliver staff-led service
improvement. At Leicester, frontline staff are leading a range
of improvement projects, for example to improve anaesthetic
checks, introduce floor-control visits in orthopaedic theatres
and simplify recruitment processes. While there are differences
in the approaches used, the focus is on developing rather than
disempowering frontline staff, building a foundation of technical
knowledge in the organisation and creating a culture that
promotes innovation.
Board members should ask the following questions• Do we have a strategy to support continuous learning,
innovation and improvement?
• Have we invested resources in building the capacity needed
to help staff innovate and improve services?
• How much senior leadership time is dedicated to supporting
frontline staff in trialling innovations and delivering
improvements?
Research shows that staff are more engaged in their work
and committed to their organisations if they believe that
their leaders act with integrity and if they have confidence
in the fairness of their organisation and its procedures. Staff
are also more engaged if they feel valued by leaders and
operate within a supportive community (Maslach et al 2001).
Conversely, we know that NHS staff are more likely to want
to leave organisations that tolerate high levels of bullying or
discrimination (Review of Staff Engagement and Empowerment
in the NHS 2014).
The message is that values are important. NHS leaders need
to attend to creating organisational cultures that help to
maintain high levels of engagement and underpin safe, high-
quality patient care. At Frimley Park Hospital Foundation Trust,
for example, there has been a conscious effort to define the
trust’s core values and the behaviours that should underpin
them, including honesty, fairness and compassion.
Statements on culture can play a useful role. But it is critically
important that leaders are seen to act authentically and that
organisations live by the values they espouse. Staff are likely
to become cynical and detached if they detect a gap between
what leaders say and what they do, what leaders claim is
important and where they really focus their energies, or between
the stated values and the behaviours that are encouraged or
tolerated in practice.
5 Establish a culture based on integrity and trust
authenticity
VALUES
integrityHONESTY
compassion
fairness
TRUST
As well as defining their values, successful trusts such as Frimley
Park Hospital Foundation Trust and Guy’s and St Thomas’ NHS
Foundation Trust are identifying ways of embedding them
within their systems and processes, such as their recruitment
procedures, appraisals and reward systems. A small number
of trusts, such as Wrightington, Wigan and Leigh NHS Foundation
Trust and Northumbria Healthcare NHS Foundation Trust,
are developing more effective procedures to address behaviours
that are inconsistent with their values, such as incivility,
aggression, bullying and harassment, whether in relation
to patients or other staff.
Board members should ask the following questions• Do we have a clear sense of the values and behaviours
that we want to promote in the organisation?
• What are we doing to promote those values and to address
behaviour that is inconsistent with them?
• What actions have we taken recently to tackle bullying
and harassment in the organisation?
Our final message is that the boards of NHS organisations need
to dedicate greater time and attention to staff engagement, not
as a passing fad, but as a subject demanding regular discussion
and reflection. Senior leaders need to place staff engagement in
the ‘too-important-to-ignore’ tray, alongside patient experience,
patient safety and clinical outcomes, given the sheer weight of
evidence that engaged staff raise these measures of the quality
of care.
In a major recent study, researchers investigated what the
boards of NHS trusts and foundation trusts considered to be
their strategic priorities and what types of innovations they
were introducing to improve quality and safety. The boards
of 38 per cent of the providers investigated identified staff
engagement as a key priority. But only 30 per cent of these
had introduced any innovations to increase engagement in
the 18 months from January 2010 to June 2011 (Dixon-Woods
et al 2014).
Other research has shown that senior leaders need to treat
staff engagement as an ongoing priority and, in many cases,
make gradual changes in a potentially wide range of areas
to create highly engaged organisations (Review of Staff
Engagement and Empowerment in the NHS 2014). For example,
the board of Bromley Healthcare discusses staff engagement
at each of its board meetings, as a standing item alongside
quality of care. Wrightington, Wigan and Leigh NHS Foundation
6 Place staff engagement firmly on the board agenda AGENDA
1. Staff
engagement
Trust has monthly staff engagement meetings, led by the chief
executive, with other board members, staff and staff-side
representatives.
Boards can use the NHS Staff Survey as an excellent starting
point for these discussions. It also offers a basis for ongoing
innovation and evaluation, given the range of comparative data
that it provides on both the conditions for engagement and
levels of engagement within trusts, such as leadership styles,
fairness of procedures, levels of trust and other features of the
working environment.
Board members should ask the following questions• How often does the board discuss levels of staff
engagement and how they could be improved?
• Are we making best use of the NHS Staff Survey and
do we need other data to assess levels of engagement
in different teams?
• What steps have we taken to increase levels of staff
engagement in the past year?
The King’s Fund has a wealth of experience in working
with NHS organisations and can support you in developing
and delivering a collective leadership strategy and a culture
of high engagement.
Our starting point is an assessment of your organisation’s
existing leadership and culture. We have developed and tested
a cultural assessment tool, which can be used separately or in
combination with a wider programme of support.
The tool provides an overview of the following aspects of culture
within your organisation:
• clarity of vision, objectives and direction
• quality of management, leadership and supervision
• devolution of responsibility
• teamworking and inter-teamworking, focusing on clarity
of objectives, roles, communication, team-learning and
cross-boundary working
• support, positivity and compassion – between staff and
patients but also between managers, leaders and staff
• pressure of work, performance monitoring, efficiency
and effort
Support from The King’s Fund
Support from The King’s Fund
• learning, innovation, outward focus, emphasis on quality
and on quality improvement
• flexibility, traditionalism, bureaucracy and formalisation.
Once we have understood the current culture, our focus
is then on engaging with senior leadership teams and on
supporting them to develop and deliver a collective leadership
strategy. Our aim is to work collaboratively, providing the
support you need at each of the three stages of discovery,
design and delivery.
This could include conducting desk research and workshops
to assess the gap between current and future leadership culture,
help in designing the new leadership strategy and providing a
range of development interventions for leaders and their teams
to embed the new culture.
Our expertsOur work is led by Dr Katy Steward and Professor Michael West.
Katy Steward is Assistant Director of Leadership
Development at The King’s Fund. She has more
than 25 years’ experience in development and
organisational change, and she is a qualified
coach. Prior to joining The King’s Fund, Katy worked at Monitor,
where she developed the first NHS foundation trust code
of governance. She has led the Fund’s Board Leadership
Programme for seven years.
Support from The King’s Fund
Michael West is a senior fellow at The King’s
Fund and Professor of Work and Organisational
Psychology at Lancaster University Management
School. The focus of Michael’s research for more
than 30 years has been culture and leadership in organisations.
He has led the Department of Health’s Policy Research
Programme into cultures of quality and safety in the NHS
in England. He has built an unparalleled evidence base around
organisational culture and staff engagement in the NHS.
Getting in touchFor an informal discussion on how we can work with your
organisation please contact Katy Steward at k.steward@
kingsfund.org.uk
If you would like to read more about collective leadership,
further information can be found at www.kingsfund.org.uk/
collectiveleadership
This paper was written by Ben Collins. It draws on staff
engagement work carried out both by the Fund and externally,
particularly the work of Professor Michael West and Improving
NHS care by engaging staff and devolving decision-making,
the report of the Review of Staff Engagement and Empowerment
in the NHS, commissioned by the Cabinet Office in 2014 and
chaired by Professor Chris Ham. Ben is a project director at
The King’s Fund.
About the author
Bezrukova K, Thatcher SMB, Jehn K, Spell CS (2012). ‘The effects of
alignments: examining group faultlines, organizational cultures and
performance’. Journal of Applied Psychology, vol 97, no 1, pp 77–92.
Dixon-Woods M, Baker R, Charles K, Dawson J, Jerzembek G, Martin G,
McCarthy I, McKee L, Minion J, Ozieranski P, Willars J, Wilkie P, West MA (2014).
‘Culture and behaviour in the English National Health Service: overview of
lessons from a large multimethod study’. BMJ quality and safety, vol 23,
no 2, pp 106–15.
MacLeod D, Clarke N (2009). Engaging for success: enhancing performance
through employee engagement. London: Department for Business,
Innovation and Skills. Available at: www.engageforsuccess.org/wp-content/
uploads/2012/09/file52215.pdf (accessed on 20 January 2015).
Maslach C, Schaufeli WB, Leiter MP (2001). ‘Job burnout’, in Fiske ST, Schacter
DL, Zahn-Waxler C (eds), Annual Review of Psychology, vol 52, pp 397–422.
NHS Confederation, Local Government Association, Age UK (2012).
Delivering dignity: securing dignity in care for older people in hospitals
and care homes. London: NHS Confederation, Local Government Association,
Age UK.
NHS Staff Survey (2013). ‘Survey results’. NHS staff survey website.
Available at: www.nhsstaffsurvey.com (accessed on 20 January 2015).
Plsek P (2013). Accelerating health care transformation with lean and
innovation: the Virginia Mason experience. New York: Productivity Press.
References
References
Review of Staff Engagement and Empowerment in the NHS (2014).
Improving NHS care by engaging staff and devolving decision-making.
London: The King’s Fund. Available at: www.kingsfund.org.uk/publications/
articles/improving-nhs-care-engaging-staff-and-devolving-decision-making
(accessed on 20 January 2015).
Steward K (2014). Exploring CQC’s well-led domain: how can boards ensure
a positive organisational culture? London: The King’s Fund. Available
at: www.kingsfund.org.uk/publications/exploring-cqcs-well-led-domain
(accessed on 20 January 2015).
The Point of Care Foundation (2014). Staff care: how to engage staff
in the NHS and why it matters. London: The Point of Care Foundation.
Available at: www.pointofcarefoundation.org.uk/What-We-Do/
(accessed on 26 January 2015).
Towers Perrin HR Services (2003). Working today: understanding
what drives employee engagement. Available at: www.ifcaonline.com/
wordpress2/wp-content/uploads/2013/10/Working-Today-What-Drives-
Employee-Engagement.pdf (accessed on 20 January 2015).
West M, Dawson JF (2012). Employee engagement and NHS
performance. London: The King’s Fund. Available at: www.kingsfund.
org.uk/publications/leadership-engagement-for-improvement-nhs
(accessed on 20 January 2015).
West M, Eckert R, Steward K, Pasmore B (2014). Developing collective
leadership for health care. London: The King’s Fund and the Center for
Creative Leadership. Available at: www.kingsfund.org.uk/publications/
developing-collective-leadership-health-care (accessed on 20 January 2015).
References
About The King’s FundThe King’s Fund seeks to understand how the health system
in England can be improved. Using that insight, we help to
shape policy, transform services and bring about behaviour
change. Our work includes research, analysis, leadership
development and service improvement. We also offer a wide
range of resources to help everyone working in health to
share knowledge, learning and ideas.
www.kingsfund.org.uk
@thekingsfund
The King’s Fund
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London W1G OAN
Tel: 020 7307 2400
Registered charity: 1126980
February 2015
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